The NHS is under significant pressure, as the “quademic” of flu-like illnesses hits the UK, with some hospitals introducing emergency measures.
While pressures may ease as the winter passes, the health service may well face further challenges.
As the UK sees growing geopolitical threats ranging from cyber warfare to direct attacks, defence leaders have raised questions about the preparedness of British society.
One former defence adviser said that missile strikes were “beyond the comprehension of most of the UK population” but were a growing risk, and that the country needed to bolster its civil defence preparation.
While the risk of all-out war involving the UK is not imminent, the military is bracing for a new set of threats. There are more ongoing conflicts globally than at any time since the Second World War.
Last year, the outgoing head of the army called, General Sir Patrick Sanders warned that war with Russia would be a “whole-of-nation undertaking”, while former senior officer General Sir Richard Barrons said conscription could be necessary.
But little has been said about the impact some form of conflict would have on the NHS, which is devolved across the UK, and how it would cope.
From cyber attacks to demand for blood soaring, or even direct attacks on hospitals, it would have to adapt rapidly. Here, defence and health experts share their advice to ready the NHS for conflict:
Embracing digital advances, improving remote care and delegating jobs from doctors to pharmacists and nurses would help make the NHS more flexible and able to respond to a wide range of threats – particularly if hospitals were damaged or overwhelmed.
“An efficient and adaptable NHS will perform better in a crisis scenario,” said Ed Harding, managing director of the Health Policy Partnership. “Conflict or no conflict, we desperately need successes in alleviating pressures on the acute system, which includes moving services out into the community wherever we can, and supporting that via new roles but also digital options and better data sharing.”
“As well as freeing up beds, this can also have the benefit of taking them closer to patients and optimising quality of life. This will make the NHS more resilient to attacks upon critical infrastructure. Sadly, hospitals and healthcare services have hardly been spared from attacks in the Ukraine and we have to assume the same could happen here.”
Cutting edge technology could help with this, Mr Harding said, citing a recent advance in echocardiogram heart scans which means they can now be carried out by handheld, mobile devices at the patient’s home, rather than in hospital with long wait times.
Another is virtual wards, where stable patients are sent home with a device to monitor their vitals – which are tracked in real time by a hospital-based team – and receive visits from nurses.
“The more practiced we are at this, the more likely we could scale up acute supervision or adapt if hospital infrastructure was overwhelmed or damaged, and in the meanwhile we free up beds for others,” Mr Harding said.
Paramedics carrying elderly woman through University Hospital Coventry ward to be returned back to her nursing home (Photo: Lynsey Addario/Getty)The NHS should also invest more in accessible, flexible medical records, experts said.
These are currently available on the NHS app or website but may only display recent updates, and patients may have to contact their GPs for longer term records. GPs won’t be able to share health information from treatment at hospitals or other services, unless they have been shared with the patient’s GP.
“As we’ve seen in Ukraine, during times of conflict you often have lots of people moving around, we saw refugees from Ukraine moving into neighbouring countries, and doctors there were often unable to access their prior care records.
“We need to ensure a secure and accessible supply of comprehensive patient data to different NHS teams and settings. A good example is better use of Electronic Product Information – whereby we provide more diverse and supportive data to patients on their medication or medical device via their smartphones, so enabling them to manage themselves more effectively.”
2. Boost cyber security
The NHS has already been hit by cyber attacks such as the 2017 Wannacry ransomware incident, which disrupted ambulance, GP and chemotherapy care in the North East.
Experts warned this could worsen significantly if tensions rise with Russia, with a senior Cabinet minister warning the UK must prepare “exceptionally aggressive and reckless” cyber warfare.
Dan Jeffrey – a former Chief Information Security Officer in the NHS who is now managing director at cyber firm Daintta – said that although good progress had been made, the NHS still needed to bolster its cyber resilience.
“Cyber developments can bolster productivity and save millions of hours of staff time. The challenge is that if we adopt AI en masse now, we don’t have consistent, infrastructural foundations at the local level which mean it could open us up to more risk,” Mr Jeffrey said.
Ambulance services in the North East were disrupted by the 2017 Wannacry attack (Photo: Peter Nicholls/Getty)“Cyber actors, be they military or civilian, will look for easiest, cheapest target. If you have wobbly infrastructure delivered without resilience and security in mind, and a workforce burnt out and understaffed, causing harm becomes a piece of cake.”
To improve, the central NHS could make local trusts deliver plans for improving their cyber security, better utilise free services provided by the National Cyber Security Centre, and focus on strengthening its supply chain.
“Since WannaCry, the major breaches in the healthcare service have been in its supply chain, rather than within the NHS itself,” he said.
“Last year, Synnovis [a pathology laboratory which processes blood tests on behalf of a number of NHS organisations] was the victim of a cyber attack, and this had massive financial repercussions.”
The NHS has a range of plans for emergency situations ranging from nuclear incidents to the evacuation of sites to mass casualty events, and a programme bolstering cyber security which includes its supply chain.
The health service’s digital team provides onsite assessments to help NHS organisations identify vulnerabilities, and brings in an external service to measure cyber risk. It is constantly flagging and responding to cyber alerts, ranking them by threat level and responding according.
Promoting general public health carries “huge strategic interest”, making the population better prepared for crises and easing the burden on the NHS, according to Mr Harding.
“The UK and its allies need their societies and economies to be as productive and their workforce agile,” the health expert said.
“In the decades to come, this will mean ensuring that we stay healthy, active, and able to contribute for as long as possible, including in later life. We know from previous conflicts that people who might not have been an active part the labour market due to age or disability may be required to start doing other jobs – for example by coming out of retirement to backfill jobs vacated by others.”
A major factor in improving the health of the nation will be tackling obesity, with the rollout of weightloss jabs such a Ozempic likely to be a key tool.
4. Don’t overlook routine care
The NHS must have plans in place to continue routine services as well as respond to crisis events, experts said.
Lessons can be drawn from the Covid-19 pandemic. Mr Harding said the NHS focused on infectious disease control but “dropped the ball” on long-term health conditions.
“The burden of healthcare need is focused on a those living with existing chronic conditions – such as cancer, cardiovascular disease, osteoporosis – and will not go away in any emergency scenario,” he said. “During the pandemic we suffered huge setbacks in term of missed or cancelled diagnostics, operations and routine reviews.”
The four global threats the UK military is most worried about in 2025
Read MoreAt least 1.5 million NHS operations were cancelled by mid 2021, according to the University of St Mary’s London, while between March and November 2020, referrals for suspected lung cancer were down to 35 per cent of pre-pandemic levels, equating to 18,000 missed people.
“This has had serious consequences, such as a significant uptick in excess mortality,” Mr Harding added. “If we look at wars around the world we see a huge increase in mortality from non-violent causes, arising from the disruption and collapse of public services, such as healthcare and sanitation.”
There are a series of laws in place which mean the NHS must be able demonstrate that they can deal with critical incidents while maintainingservices to patients, and the service says it has a clear leadership pathway with accountable decision-making in response to any crisis.
It also conducts targeted training and exercising programme to ensure staff know how to follow the plans.
5. Integrate health planning with everything else
To prepare the NHS for conflict, health, defence and economic planning should be better integrated, experts said.
Ed Arnold, a senior research fellow at defence thinktank RUSI, and Colonel Si Horne, a British Army fellow at RUSI, said this was increasingly important amid trends towards fighting in urban areas, which will “produce a corresponding increase in civilian and military casualties at the same time, which will not easily be separated, so each will end up in the other’s medical system”.
One easy step is to include the Health Secretary as a member of the National Security Council, they said.
Mr Harding said the Covid-19 pandemic taught us that “we need to think of health as intrinsic to the wider economy and society”.
Medical historian called Dr Martin Moore of the University of Exeter said that lessons in planning could be drawn from the Emergency Medical Service in the late 30s.
Widely considered the precursor to the NHS, the service ensured that in case of conflict, hospitals – including over 1,000 operating theatres – labs and workers were able to be mobilised, along with forms of home defence.
It secured blood for transfusions, stockpiles of bandages, and system of air raid preparation among civilians to address potential physical and psychological trauma.
“We’ve seen in pandemic how a lack of preparations – or preparing for a different crisis to the one being faced – can lead to severe outcomes,” he said.
A Welsh Government spokesperson said it would work with the UK Government on plans to ensure the NHS in Wales is as prepared as its counterparts.
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